Incidence survey of Kawasaki disease in 1997 and 1998 in Japan

Kawasaki Disease-Associated Cytokine Storm Syndrome

Kawasaki disease (KD) is a hyperinflammatory syndrome manifesting as an acute systemic vasculitis characterized by fever, nonsuppurative conjunctival injection, rash, oral mucositis, extremity changes, and cervical lymphadenopathy. KD predominantly affects young children and shares clinical features and immunobiology with other hyperinflammation syndromes including systemic juvenile idiopathic arthritis (sJIA) and multisystem inflammatory syndrome in children (MIS-C). Cytokine storm syndrome (CSS) is an acute complication in ~2% of KD patients; however, the incidence is likely underestimated as many clinical and laboratory features of both diseases overlap. CSS should be entertained when a child with KD is unresponsive to IVIG therapy with recalcitrant fever. Early recognition and prompt institution of immunomodulatory treatment can substantially reduce the mortality and morbidity of CSS in KD. Given the known pathogenetic role of IL-1β in both syndromes, the early use of IL-1 blockers in refractory KD with CSS deserves consideration.

Hygiene Hypothesis as the Etiology of Kawasaki Disease: Dysregulation of Early B Cell Development

Kawasaki disease (KD) is an acute systemic vasculitis that occurs predominantly in children under 5 years of age. Despite much study, the etiology of KD remains unknown. However, epidemiological and immunological data support the hygiene hypothesis as a possible etiology. It is thought that more sterile or clean modern living environments due to increased use of sanitizing agents, antibiotics, and formula feeding result in a lack of immunological challenges, leading to defective or dysregulated B cell development, accompanied by low IgG and high IgE levels. A lack of B cell immunity may increase sensitivity to unknown environmental triggers that are nonpathogenic in healthy individuals. Genetic studies of KD show that all of the KD susceptibility genes identified by genome-wide association studies are involved in B cell development and function, particularly in early B cell development (from the pro-B to pre-B cell stage). The fact that intravenous immunoglobulin is an effective therapy for KD supports this hypothesis. In this review, I discuss clinical, epidemiological, immunological, and genetic studies showing that the etiopathogenesis of KD in infants and toddlers can be explained by the hygiene hypothesis, and particularly by defects or dysregulation during early B cell development.

Diagnostic accuracy of N-terminal pro-brain natriuretic peptide for Kawasaki disease: An updated systematic review and meta-analysis

OBJECTIVE

This study aimed to investigate the diagnostic accuracy of circulating N-terminal pro-brain natriuretic peptide (NT-proBNP) for Kawasaki disease (KD).

METHODS

We searched the PubMed, Web of Science and EMBASE databases to identify the eligible studies investigating the diagnostic accuracy of NT-proBNP for KD. The revised tool for the quality assessment of diagnostic accuracy studies (QUADAS-2) was used to evaluate the eligible studies' quality. A meta-analysis was performed with the bivariate model and summary receiver operating characteristic (sROC) curve. We also performed subgroup, publication bias and sensitivity analyses.

RESULTS

We included 12 studies with 2173 KDs and 1909 control. The pooled sensitivity and specificity of eligible studies were 0.80 (95%CI: 0.72-0.86) and 0.81 (95%CI: 0.73-0.88), respectively. The area under sROC curve was 0.88 (95%CI: 0.84-0.90). Patient selection bias and partial verification bias were the major design weakness of the eligible studies. Sensitivity analysis revealed that the results of this meta-analysis were robust. Subgroup analysis revealed that study design, NT-proBNP assay and participants' body temperature were not the source of heterogeneity across all eligible studies. No publication bias was observed.

CONCLUSION

NT-proBNP has moderate diagnostic accuracy for KD. It cannot be used for ruling in or ruling out KD when used alone.

Epidemiology and Risk Factors for Giant Coronary Artery Aneurysms Identified After Acute Kawasaki Disease

A giant coronary artery (CA) aneurysm is a potentially fatal cardiac complication resulting from Kawasaki disease (KD). We aimed to identify epidemiologic characteristics and potential risk factors associated with giant CA aneurysms identified after acute KD. We analyzed 90,252 patients diagnosed with KD from 2011 to 2018, using data obtained in nationwide KD surveys conducted in Japan. Multivariable logistic regression analyses were performed to evaluate potential risk factors associated with subsequent giant CA aneurysm complications (defined as lumen size ≥ 8 mm), adjusting for all potential factors. Giant CA aneurysms were identified in 144 patients (0.16%) after acute KD. The annual prevalence ranged from 0.07 to 0.20% during the study period. In the multivariate analyses, male sex (adjusted odds ratio 2.09 [95% confidence interval 1.41-3.11], recurrent KD (1.90 [1.09-3.33]), IVIG administration at 1-4 days of illness (1.49 [1.04-2.15]) and ≥ 8 days after KD onset (2.52 [1.38-4.60]; reference, 5-7 days), detection of CA dilatations and aneurysms at initial echocardiography (4.17 [1.85-5.41] and 46.5 [28.8-74.8], respectively), and resistance to IVIG treatment (6.09 [4.23-8.75]) were significantly associated with giant CA aneurysm complications identified after acute KD. The annual prevalence of giant CA aneurysms identified after acute KD did not increase during the study period. Patients with larger CA abnormalities detected at initial echocardiography were independently associated with progression to giant CA aneurysm complications after acute KD regardless of the number of days from onset at treatment initiation.

Atypical recurrent Kawasaki disease with retropharyngeal involvement: A case study and literature review

Kawasaki disease (KD) is a systemic inflammatory condition primarily affecting young children. We present an adolescent male with two episodes of complete KD between the age of 2 and 14 years. At age 14, he presented with findings suggestive of a retropharyngeal abscess. This was later determined to be a recurrence of KD, diagnosed after the development of coronary artery aneurysms. Our case reinforces the role of maintaining a high index of suspicion for KD, both in patients with prior KD episodes and in those with persistent fever who do not fulfill the diagnostic criteria for typical KD. This is particularly important for patients presenting with atypical symptoms not commonly associated with KD, such as inflammation of the retropharyngeal and parapharyngeal spaces.

The rs1625579 T>G polymorphism in the miRNA-13 gene confers a risk of early- onset Kawasaki disease in a southern Chinese population

Background

Kawasaki disease (KD) mainly manifests as excessive inflammation and vascular endothelial cell injury. This disease generally occurs in children younger than 5 years of age and is more severe in children younger than 12 months. KD affects males and females at a ratio of 1.5:1. Polymorphisms of the rs1625579 locus in the miR-13 gene are associated with schizophrenia susceptibility, and high glucose-induced upregulation of miR-137 in vascular endothelial cells promotes monocyte chemotaxis and inflammatory cytokine secretion in gestational diabetes mellitus. However, researchers have not reported whether rs1625579 is associated with KD susceptibility or onset. Therefore, we investigated the relationship between the miRNA-13 rs1625579 T>G polymorphism and KD susceptibility.

Methods

TaqMan real-time polymerase chain reaction was applied to determine the genotypes of 532 patients with KD (365 males and 167 females) and 623 control subjects (402 males and 221 females).

Results

Comparison of all cases with all controls revealed that the rs1625579 T>G polymorphism was not associated with KD susceptibility. However, a subgroup analysis revealed that subjects with the rs1625579 TG/GG genotypes exhibited a significantly higher onset risk for KD before 12 months of age than carriers of the TT genotype (adjusted age and gender odds ratio=1.99, 95% CI=1.04-3.83; P=0.039).

Conclusion

Our results indicate that the rs1625579 T>G polymorphism confers a risk of early-onset KD in southern Chinese children.

Kawasaki disease: Epidemiological differences between past and recent periods, and implications of distribution dynamism

BACKGROUND

Epidemiological findings suggest that Kawasaki disease (KD) is mediated by infection, which triggers its onset. Although the mechanism of onset seems to involve preconditioning factors and triggering factors, the details remain unclarified.

METHODS

Data for 330 662 patients reported in KD nationwide surveys in Japan implemented between 1961 and 2014 were chronologically compared in terms of patient age distribution, estimated mean onset age, and male-to-female ratio during four periods: pre-epidemic (P1), epidemic (P2), stable (P3), and recent (P4): 1961-1978, 1979-1986, 1987-1997, and 1998-2014, respectively.

RESULTS

During P2, the number of patients aged 6 months-2 years increased, and the mean onset age was younger; during P4, however, the number of patients aged ≤1 year decreased, but the number of patients ≥2 years increased, with a flat onset age distribution chart, and the mean onset age was older. During P2, increases in the number of patients were accompanied by younger mean onset age, whereas during P4, increases in the number of patients were conversely accompanied by older mean onset ages. The male: female ratio tended to decrease during P2, but this tendency was not seen in P4. No outbreak occurred during a recent 28 year period (P3, P4). Specific preconditioning factors might have been present during the 8 years (P2) of the past three outbreaks.

CONCLUSION

P2 and P4 were significantly different in epidemiological features. It is likely that they do not share the same mechanism of onset (preconditioning and/or trigger factors).

Cumulative incidence of Kawasaki disease in Japan

BACKGROUND

Although the incidence rates of Kawasaki disease (KD) in Japan have been determined in nationwide surveys, the cumulative incidence, that is, the proportion of those with a history of KD in the general population of 10-year-olds, is currently unknown. The aim of this study was therefore to assess the cumulative incidence of KD in Japan.

METHODS

Using the age- and sex-specific incidence rate of KD in Japan from the results of the nationwide surveys, incidence probabilities, that is, the age-specific number of KD patients divided by the population used in the vital statistics, and cumulative proportions of those not affected by KD up to the end of 9 years of age, were calculated. The cumulative incidence was then defined as 1 minus the cumulative proportion. The observed age classes were 0, 1, 2, 3, 4, and 5-9 years. All data were calculated by sex.

RESULTS

The cumulative incidence was 0.004833 for boys and 0.003474 for girls in 1991, but was 0.015284 and 0.012145 in 2014, respectively. According to these figures, 15.284 per 1,000 boys and 12.145 per 1,000 girls have been affected by KD by the age of 10 years. The birth-cohort cumulative incidences had similar trends.

CONCLUSIONS

More than 10 persons in 1,000 have a history of KD at age 10 years in Japan.

Cardiac Complications, Earlier Treatment, and Initial Disease Severity in Kawasaki Disease

OBJECTIVES

To assess if observed higher observed risks of cardiac complications for patients with Kawasaki disease (KD) treated earlier may reflect bias due to confounding from initial disease severity, as opposed to any negative effect of earlier treatment.

STUDY DESIGN

We used data from Japanese nationwide KD surveys from 1997 to 2004. Receipt of additional intravenous immunoglobulin (IVIG) (data available all years) or any additional treatment (available for 2003-2004) were assessed as proxies for initial disease severity. We determined associations between earlier or later IVIG treatment (defined as receipt of IVIG on days 1-4 vs days 5-10 of illness) and cardiac complications by stratifying by receipt of additional treatment or by using logistic modeling to control for the effect of receiving additional treatment.

RESULTS

A total of 48 310 patients with KD were included in the analysis. In unadjusted analysis, earlier IVIG treatment was associated with a higher risk for 4 categories of cardiac complications, including all major cardiac complications (risk ratio, 1.10; 95% CI, 1.06-1.15). Stratifying by receipt of additional treatment removed this association, and earlier IVIG treatment became protective against all major cardiac complications when controlling for any additional treatment in logistic regressions (OR, 0.90; 95% CI, 0.80-1.00).

CONCLUSIONS

Observed higher risks of cardiac complications among patients with KD receiving IVIG treatment on days 1-4 of the illness are most likely due to underlying higher initial disease severity, and patients with KD should continue to be treated with IVIG as early as possible.

Nationwide Survey of Patients With Giant Coronary Aneurysm Secondary to Kawasaki Disease 1999-2010 in Japan

BACKGROUND

Giant coronary aneurysm is the most severe sequela in Kawasaki disease, occurring in approximately 0.2% of patients in Japan. Regression is rare, while myocardial infarction (MI) and sudden death are relatively common. Herein, we reviewed patients with giant coronary aneurysm in a 10-year period.Methods and Results:A nationwide questionnaire survey was conducted based on a national epidemiological database from 1999 to 2010. We identified 355 giant coronary aneurysm patients, of whom 209 were analyzed. The 5- and 10-year total cardiac event-free rates were 0.72 and 0.68, respectively. Twelve patients died, and MI was observed in 32 patients (18.1%). Five and 6 deaths were due to coronary rupture and MI, respectively. All ruptures occurred within 1 month of onset, while most MI occurred within 18 months. There was no death beyond 2 years. Aneurysm size was significantly related to the occurrence of MI in both the right and left coronary arteries. At the time of writing, 55% of patients had no exercise limitations. And including patients who cannot perform strenuous exercises, 81% of patients were leading ordinary lives.

CONCLUSIONS

Severe cardiac events are likely to occur within 2 years from onset of Kawasaki disease, while no deaths occurred beyond this time. Hence, careful monitoring is needed especially for the first 2 years. Most patients with giant coronary aneurysms can lead ordinary lives with appropriate management.

Twelve Years of Kawasaki Disease in Portugal: Epidemiology in Hospitalized Children

BACKGROUND

Kawasaki disease (KD) is the leading cause of acquired heart disease in developed countries. Reported incidences vary worldwide but incidence of KD has not been established in Portugal.

AIM

The aims of the study were to describe the epidemiologic characteristics and estimate incidence rates of KD among hospitalized children in Portugal.

METHODS

This study was a descriptive, population-based study, which used hospital discharge records of patients <20 years of age diagnosed with KD from the Hospital Register database for 2000-2011. Incidence rates were calculated using the number of KD patients and corresponding National census data.

RESULTS

There were 533 hospitalizations of 470 patients with KD as the primary diagnosis in Portugal, 63 hospitalizations were transfers of patients between hospitals and there were no relapses. The mean age at admission was 2.8 years, with male predominance (male-to-female ratio: 1.6:1). Children <5 years and infants <1 year represented 83% and 23% of all the patients admitted, respectively. Mean annual incidence was 6.5 per 100,000 children <5 years, 4.5 per 100,000 infants <1 year and 7.8 per 100,000 infants 1-4 years. We found considerable differences between national territorial regions, with majority of cases in most dense regions. The mean length of hospital stay was 9 days, and the incidence peaked in spring (35%) and spring/winter (63%). Coronary aneurysms were reported in 8.5% of patients with a higher male-to-female ratio (3.4:1) and a lower mean age (1.93 years). Reported mortality was 0.4%.

CONCLUSIONS

This is the first large-scale epidemiologic study of KD in Portugal. The highest incidences occurred among male children 1-4 years of age and in spring/winter.

Kawasaki Disease: An Autopsy Case Series and Review of the Literature

INTRODUCTION

Kawasaki disease (KD) is a major cause of acquired heart disease in children, and there is limited information on postmortem findings in the pediatric population in Canada.

CASES

For a 15-year time span (January 2000-March 2015), we had 2 cases of KD presented to the Department of Forensic Pathology at Hamilton General Hospital.

DISCUSSION

There were common cardiac findings including presence of giant coronary artery aneurysms and microscopic changes occurring within the coronary arteries and the myocardium. Evidence of old infarction was present in both heart specimens, but acute infarction was noted in one of the specimens.

CONCLUSIONS

This case series documents postmortem findings that outline cardiac complications of KD including aneurysms, thrombotic events, and infarcts. In addition to addressing the medical complications of KD, it is also important to address the psychosocial effect due to its impact on quality of life.

[A review of Kawasaki disease, a perspective from the articles published in Mexico since January 1977 to May 2012]

Kawasaki disease was described in 1967 by Tomisu Kawasaki. It affects children aged between one and 5 years, and it evolves with fever and small vessel vasculitis, which leads to cardiovascular complications, including coronary aneurisms, myocarditis, valve injuries, pericardial effusion and myocardial infarction; eventually involving many others organs. The etiology actually is not well known, as the exactly pathogenic mechanisms; however, now there are important advances. If the clinical signs and symptoms are identify early and the children received treatment with aspirin and intravenous immunoglobulin, the patients evolves without sequels. The Kawasaki disease is an infrequent disease in Mexico.

An infant with γ-globulin-induced hypersensitivity syndrome who developed Evans' syndrome after a second γ-globulin treatment

Abstract One month after treatment with γ-globulin for Kawasaki disease, an 18-month-old girl developed Evans' syndrome in addition to drug-induced hypersensitivity syndrome (DIHS) after a second γ-globulin treatment. She suffered from hyperbilirubinemia, hemolytic anemia, and thrombocytopenia. The findings and her clinical course involved plasma exchange and treatment with prednisolone, with good results. Peripheral lymphocyte stimulation tests indicated that γ-globulin was the likeliest cause of the DIHS. A real-time polymerase chain reaction test showed the human herpes virus (HHV)-6 genome in peripheral blood. We demonstrated that a primary infection or infection reactivation by the HHV-6 virus was involved in the development of γ-globulin-induced hypersensitivity and Evans' syndrome.

National Japanese survey of thrombolytic therapy selection for coronary aneurysm: intracoronary thrombolysis or intravenous coronary thrombolysis in patients with Kawasaki disease

BACKGROUND

Thrombolytic therapy for coronary aneurysm thrombosis of Kawasaki disease (KD) includes antiplatelet and anticoagulants, i.v. coronary thrombolysis (IVCT), and i.c. thrombolysis (ICT). Therapeutic methods, drugs and doses vary among medical facilities.

METHODS AND RESULTS

A nationwide survey of thrombolytic therapy was conducted under the auspices of the Ministry of Health, Labour and Welfare Research Program to Intractable Diseases Research Grants. A secondary survey targeted 14 facilities conducting thrombolytic therapy during a 5 year period (2004-2009). The primary survey investigated performance of thrombolytic therapy for 23 KD patients at 14 facilities, and of these, five with acute myocardial infarction had received ICT and combined therapy. The secondary survey investigated the pre-treatment condition of aneurysm and thrombosis and actual treatment methods. ICT was effective for small thrombi (≤ 10 mm), while IVCT was effective even for giant thrombi (>10 mm). ICT was also effective for thrombi within several hours after formation.

CONCLUSION

In the present nationwide survey, thrombolytic therapy was more effective in cases of a shorter duration between thrombus formation and the start of treatment. It was found that many facilities used only IVCT for thrombus alone. Medications given to KD children did not cause serious hemorrhagic complications, unlike in adults. Although doses exceeded recommended levels in many cases, the only complications were nasal bleeding and fever.

Kawasaki disease in infants

Kawasaki disease (KD) is an acute febrile illness that is the predominant cause of pediatric acquired heart disease in infants and young children. Because the diagnosis of KD depends on clinical manifestations, incomplete cases are difficult to diagnose, especially in infants younger than 1 year. Incomplete clinical manifestations in infants are related with the development of KD-associated coronary artery abnormalities. Because the diagnosis of infantile KD is difficult and complications are numerous, early suspicion and evaluation are necessary.

Clinical manifestations of Kawasaki disease shock syndrome: a case-control study

BACKGROUND

Kawasaki disease shock syndrome (KDSS) is a severe condition related to Kawasaki disease (KD), and sometimes it is difficult to diagnose. This is a case-control study to ascertain the clinical presentations, risk factors, and clinical outcomes of children who had KDSS.

MATERIALS AND METHODS

Children who were hospitalized during 2001-2011 with the diagnosis of KD combined with hypotension, sepsis, or shock were retrospectively reviewed and were defined as case patients. For each case patient, three season-matched patients diagnosed as having KD with normal blood pressure were identified to serve as control patients. Demographic characteristics, clinical presentations, laboratory features, therapies, and outcomes were analyzed.

RESULTS

Nine KDSS patients and 27 control patients were identified. The average age of patients with KDSS was 3.2 ± 3.2 years. Compared with controls, KDSS patients were less likely to have a diagnosis of KD at admission (22.2% vs. 66.7%) and had a higher risk of coronary artery dilatation (77.8% vs. 11.1%). Risk factors for KDSS included higher neutrophil counts and proportions of bands, higher C-reactive protein (CRP), and lower platelet counts. All case patients received aspirin therapy; eight patients received intravenous immunoglobulin therapy, with two receiving more than one course. Seven KDSS patients required fluid resuscitation, and eight patients required vasoactive infusions.

CONCLUSION

Patients with KDSS may have uneven clinical course and may be misdiagnosed in the beginning. They may have more prominent inflammatory markers in the early phase and higher risk of coronary artery dilatation.

Kawasaki disease in Thai infants compared with older children

Infants with Kawasaki disease (KD) are at increased risk of having coronary artery abnormalities (CAA). The purpose of this study was to evaluate the clinical features of KD in infants and compare these with findings in older children to determine the risk factors for CAA in infants. All children with KD admitted to a tertiary care hospital between January 1993 and April 2003 were studied retrospectively. Of a total of 51 patients included in the study, 22 (43%) were <1 year of age (mean 8 months, range 2-12 months). All had classical clinical manifestations such as fever, skin rash and mucositis; extremity change occurred in 95%, conjunctivitis in 81% and cervical lymphadenopathy in 27%. Infants had significantly more non-classical symptoms, e.g. diarrhoea (68%), than older children (38%) (p=0.04). The mean number of days before intravenous immunoglobulin (IVIG) treatment was given to infants was 2 days later than in older children. The predictors of CAA in infants were resistance to IVIG treatment (p=0.02) and long duration of fever (p=0.009). Compared with older children, the less typical presentations and delay in diagnosis and treatment in infants might be important factors in CAA in KD.

Kawasaki disease in ghana: case reports from Korle Bu teaching hospital

Kawasaki disease, an acute febrile vasculitis, predominantly affects children under the age of 5 years and is thought to be a rare disease in the developing world. It has previously never been reported in Ghana. We report 3 cases from February, 2007 to February, 2008. This potentially serious disease has no definitive diagnostic test and it is not unusual for diagnosis to be delayed with serious consequences. Any child with irritability and persisting fever (>5 days) not responding to antipyretics and antibiotics, accompanied by a rash and non purulent conjunctivitis should be suspected to have Kawasaki disease.

Preventing coronary artery abnormalities: a need for earlier diagnosis and treatment of Kawasaki disease

OBJECTIVES

The aim of this study was to explore the timing of coronary artery (CA) abnormalities in light of the expanding clinical spectrum of Kawasaki disease (KD).

METHODS

We reviewed all cases of KD admitted to Children's Hospital Colorado from January 2007 through February 2011 who had CA abnormalities. A retrospective chart review was conducted to collect demographic, clinical, laboratory and echocardiogram (ECHO) data. CA abnormalities were defined as Z score ≥2.5 or presence of ectasia or aneurysms.

RESULTS

A total of 210 patients with KD were identified. Fifty-seven (27.1%) of the 210 children with KD had CA abnormalities. Forty-six of the 57 (81%) children with CA abnormalities had CA abnormalities noted on their initial ECHO. Of the 46 children who had CA abnormalities detected on their initial ECHO, 37 (80%) had their ECHO on or before illness day 10. The median day of illness when abnormalities were detected on initial ECHO was day 7 (interquartile range: 5-8; range: 2-24 days). Only 25 of the 46 children (54%) were classified as complete KD, but 40 (87%) had the triad of conjunctivitis, rash and mucous membrane involvement. Thirteen (28%) had intravenous immunoglobulin-resistant disease.

CONCLUSION

The majority of CA abnormalities in children with KD were identified in the initial ECHO, during the first week of illness. Earlier diagnosis and treatment is needed to impact the incidence of CA abnormalities in children with KD. Increased clinical suspicion and earlier use of ECHO in the initial workup of children with suspected KD may lead to more rapid diagnosis and treatment.

Cardiac involvement in Kawasaki disease in Pakistani children

Introduction:

Coronary artery involvement is the most dreaded long-term complication of Kawasaki disease. Our aim was to look at the pattern of cardiovascular involvement in Pakistani children admitted with Kawasaki disease.

Methods:

This study included children admitted with Kawasaki disease at the Aga Khan University Hospital Karachi over a period of 14 years from January 1997 to December 2010. Information gathered included patient demographics, clinical features, investigations, echocardiographic findings, treatment and follow-up. Those with coronary artery involvement on initial echocardiogram remained on long-term follow-up with clinical examination and echocardiogram.

Results:

A total of 56 patients were admitted. (Mean age at diagnosis 33 ± 30 months, age range 2 months to 9 years). 18% of patients had incomplete features. Twenty-five percent (14/56) patients presented after 10 days of fever. Cardiac examination was normal except for tachycardia. Abnormal coronary arteries were seen in 23 patients (41%) - left main coronary artery in 23 (41%), left anterior descending and right main coronary artery in 20 (36%), circumflex branch in 17 (30%). Risk factors for cardiac involvement were male sex, fever >10 days duration at the time of initial presentation and neutrophil percentage >75% in the initial white blood cell counts. Fifty four of 56 cases received intravenous immunoglobulin (IVIG), Seventy-five percent of the patients received IVIG within 10 days of illness. Mean duration of follow-up was 2.5 years. Eight percent of the patients still continue to have abnormal coronaries. There was no mortality.

Conclusions:

A higher incidence of coronary artery involvement was found in our study. Presentation after 10 days of illness increases the risk of coronary artery involvement. High index of suspicion among the general pediatricians about the disease can possibly be helpful for early referral and treatment.

Genetic polymorphisms in Kawasaki disease

Kawasaki disease (KD) is an acute febrile systemic vasculitis, and the cause of KD is not well understood. It is likely due to multiple interactions between genes and environmental factors. The development of genetic association and genome-wide association studies (GWAS) has opened an avenue to better understanding the molecular mechanisms underlying KD. A novel ITPKC signaling pathway was recently found to be responsible for the susceptibility to KD. Furthermore, the GWAS demonstrated the functionally related susceptibility loci for KD in the Caucasian population. In the last decade, the identification of several genomic regions linked to the pathogenesis of KD has made a major breakthrough in understanding the genetics of KD. This review will focus on genetic polymorphisms associated with KD and describe some of the possible clinical implications and molecular mechanisms that can be used to explain how genetic variants regulate the pathogenesis in KD.

Kawasaki disease in Israel

OBJECTIVE

To characterize the epidemiology and estimate the incidence of Kawasaki disease (KD) among children in Israel.

METHODS

Using the Israel National Hospital Discharge Register, we investigated the epidemiologic features of KD among children <18 years of age between 1996 to 2009 in Israel. Incidence rates were calculated using the corresponding census data.

RESULTS

During 1996 through 2009, 685 children <18 years of age were hospitalized for KD in Israel. Of these children, 88% were aged <5 years; the male/female ratio was 1.7:1; and most cases occurred in late winter-early spring. The overall incidence of KD was 6.4 per 100,000 children <5 years of age. Since 2000, there was a gradual increase in KD incidence as well as in the ratio of KD-associated hospitalizations to all-cause pediatric hospitalizations. For male infants <1 year of age, KD rates almost doubled: from 5.8 per 100,000 cases in 1996-1998 to an average of 11.9 cases per 100,000 in the following years (P = 0.002). The overall proportion of patients with coronary artery aneurysm was 2.9%, higher rates of coronary artery aneurysm were observed in patients <1 or >5 years of age and in male patients.

CONCLUSIONS

Major epidemiologic features of KD among Israeli children are similar to those reported for the white population in Europe and the United States. KD incidence increased during the study period, especially among male infants <1 year of age.

Atipical Kawasaki disease with coronary aneurysm in infant

Kawasaki disease is an acute febrile disease of unknown etiology, characterized by systemic vascular inflammation involving the small and medium sized arteries, with a predilection for the coronary arteries. It represents the leading cause of acquired heart diseases in children in developed countries. Diagnosis, difficult because of the clinical characteristics of the disease with typical signs and symptoms appearing sequentially and not simultaneously, may be even more complicated in case of unusual presentation, leading to delay in recognition, particularly in infant in whom a higher incidence of coronary arteries aneurysms has been reported. A high index of suspicion of Kawasaki disease must be maintained in case of prolonged fever in these patients. Timely appropriate treatment is essential to avoid severe sequels. We report the case of a 2 months old male infant with persistent febrile episode, transferred to us from another institution, who presented on echocardiography giant aneurysms on both coronary arteries.

Identification of novel susceptibility Loci for kawasaki disease in a Han chinese population by a genome-wide association study

Kawasaki disease (KD) is an acute systemic vasculitis syndrome that primarily affects infants and young children. Its etiology is unknown; however, epidemiological findings suggest that genetic predisposition underlies disease susceptibility. Taiwan has the third-highest incidence of KD in the world, after Japan and Korea. To investigate novel mechanisms that might predispose individuals to KD, we conducted a genome-wide association study (GWAS) in 250 KD patients and 446 controls in a Han Chinese population residing in Taiwan, and further validated our findings in an independent Han Chinese cohort of 208 cases and 366 controls. The most strongly associated single-nucleotide polymorphisms (SNPs) detected in the joint analysis corresponded to three novel loci. Among these KD-associated SNPs three were close to the COPB2 (coatomer protein complex beta-2 subunit) gene: rs1873668 (p = 9.52×10⁻⁵), rs4243399 (p = 9.93×10⁻⁵), and rs16849083 (p = 9.93×10⁻⁵). We also identified a SNP in the intronic region of the ERAP1 (endoplasmic reticulum amino peptidase 1) gene (rs149481, p(best) = 4.61×10⁻⁵). Six SNPs (rs17113284, rs8005468, rs10129255, rs2007467, rs10150241, and rs12590667) clustered in an area containing immunoglobulin heavy chain variable regions genes, with p(best)-values between 2.08×10⁻⁵ and 8.93×10⁻⁶, were also identified. This is the first KD GWAS performed in a Han Chinese population. The novel KD candidates we identified have been implicated in T cell receptor signaling, regulation of proinflammatory cytokines, as well as antibody-mediated immune responses. These findings may lead to a better understanding of the underlying molecular pathogenesis of KD.

Epidemiological features of Kawasaki disease in Korea, 2006-2008

BACKGROUND

The aim of this study was to estimate the incidence and describe the epidemiological characteristics of Kawasaki disease among children in Korea.

METHODS

Questionnaires for surveying the epidemiology of Kawasaki disease were distributed to a total of 101 hospitals that conduct pediatric residency programs. Then, we retrospectively obtained the data, which covered a three-year period (2006-2008) and analyzed them.

RESULTS

During the three-year study period, a total of 9039 cases of Kawasaki disease were reported from 84 hospitals (response rate, 83.2%), comprising 5375 boys and 3664 girls (male:female ratio, 1.47:1). The outbreak rate per 100,000 children <5 years old was 108.7 in 2006, 118.3 in 2007 and 112.5 in 2008 (average rate, 113.1). The seasonal distribution showed a slightly higher incidence rate in winter and summer. The patients' mean age of onset was 32.6 months, while the proportions of sibling cases and recurrent cases were 0.17% and 2.2%, respectively. Coronary arterial abnormalities were detected during follow up by echocardiogram in 17.5% of all cases including dilatations (16.4%) and aneurysms (2.1%).

CONCLUSIONS

The average annual incidence rate of Kawasaki disease in Korea has been continuously increasing, and reached 113.1/100,000 children <5 years old, which is the second highest rate in the world.

Case-control study of giant coronary aneurysms due to Kawasaki disease: the 19th nationwide survey

BACKGROUND

The risk factors for recently reported cases of giant coronary aneurysms due to Kawasaki disease have not been elaborated.

METHODS

Fifty-three patients with giant coronary aneurysms, diagnosed as Kawasaki disease in 2005 and 2006, were selected from the 19th nationwide survey of the disease in Japan. With all the other patients recorded at the same hospitals as a control group, OR and their 95%CI were calculated to delineate the risk factors.

RESULTS

In multivariate analyses, patients aged younger than 1 year (OR compared with 1-2-year-olds = 6.57) and those older than 5 years (OR compared with 1-2-year-olds = 4.24), those who received additional intravenous immunoglobulin (IVIG) without the use of steroid (OR = 8.38) and those who received steroid administration with or without the additional use of IVIG (OR = 220.51 and 83.83, respectively), showed significantly higher OR for giant coronary aneurysms. As for IVIG therapy, the additional use of IVIG (OR = 14.84), total dosage of IVIG exceeding 2500 mg/kg (OR compared with 1500-2499 mg/kg = 12.26) and the duration of IVIG administration for more than 3 days (OR = 30.12), were found to significantly increase the risk of developing giant aneurysms in univariate analyses that were adjusted for sex and age.

CONCLUSIONS

The observation of 53 patients with giant coronary aneurysms due to Kawasaki disease among those included in the nationwide survey presented some risk factors, together with considerations about the associated aneurysms.

Clinical and epidemiological characteristics of children with Kawasaki disease in Turkey

BACKGROUND

Kawasaki disease (KD) is the leading cause of acquired heart disease in childhood in the developed countries. The objective of this study is to describe the clinical and epidemiological characteristics of children with KD in Turkey.

METHODS

The medical records of 24 patients treated for KD between January 1994 and June 2009 at Ankara University Medical School, Turkey were reviewed.

RESULTS

The male-to-female ratio was 1.4 : 1. The median age at diagnosis was 2 years (range: 6.5 months to 11 years). Conjunctivitis and changes in the lips and oral cavity were seen in 21/24 (87.5%), cervical lymphadenopathy 17/24 (70.8%), polymorphous rash 16/24 (66.7%) and peripheral changes in 12/24 (50%). Coronary artery abnormality (CAA) was observed in 8/24 (33.3%) cases. CAA was seen in both the complete and incomplete groups with similar frequency (31.3% vs. 37.5%, respectively).

CONCLUSIONS

KD must be kept in mind in the differential diagnosis of infants with prolonged fever.

Affects of "age at diagnosis" on coronary artery lesions in patients with incomplete kawasaki disease

Background and Objectives

Diagnosis of Kawasaki disease (KD) is based on 5 clinical features. Incomplete KD (IKD), which has fewer features, is more common in infants and older children, in whom the rate of coronary artery aneurysms is paradoxically higher. We conducted this study to evaluate risk factors associated with age-at-diagnosis on coronary arterial lesions (CAL) in patients with IKD.

Subjects and Methods

Retrospective data from 396 patients with KD in a single center were collected from January 2003 to July 2007. Patients were grouped according to their age at diagnosis; Group A (<1 year of age), Group B (1≤age<5 years of age), and Group C (≥5 years of age).

Results

Among a total of 396 patients with KD, 87 (22.0%) were in Group A, 246 (62.1%) in Group B, and 63 (15.9%) in Group C. In groups A and C, lag times for starting intravenous immunoglobulin (IVIG) were longer than in Group B. There were no differences in the incidence of IKD, late CAL, or rates of IVIG retreatment among the three groups. Among 174 patients with IKD, there were no age-related differences in late CAL incidence or IVIG retreatment. Compared with typical KD, duration of fever and lag times to start IVIG were longer, and the rate of IVIG retreatment was higher in IKD, but there was no difference in the risk of CAL between typical KD and IKD.

Conclusion

In the management of KD, especially the incomplete type, age-associated factors appear not to be significant for predicting the development of CAL.

Epidemiologic features of Kawasaki disease in Japan: results of the 2007-2008 nationwide survey

BACKGROUND

The most recent epidemiologic features of Kawasaki disease (KD) are unknown.

METHODS

The 20th nationwide survey of KD was conducted in 2009, and included patients treated for the disease in 2007 and 2008. Hospitals specializing in pediatrics, and hospitals with pediatric departments and 100 or more beds, were asked to report all patients with KD during the 2 survey years.

RESULTS

From a total of 1540 departments and hospitals, 23,337 patients (11 581 in 2007 and 11 756 in 2008) were reported: 13,523 boys and 9814 girls. The annual incidence rates were 215.3 and 218.6 per 100,000 children aged 0-4 years in 2007 and 2008, respectively. These were the highest annual KD incidence rates ever recorded in Japan. The monthly number of patients peaked during the winter months; smaller increases were noted in the summer months. The age-specific incidence rate showed a monomodal distribution with a peak at age 9-11 months. The prevalences of both cardiac lesions during the acute phase of the disease and cardiac sequelae were higher among infants and older age groups.

CONCLUSIONS

The incidence rate and number of patients with KD in Japan continue to increase.

Giant coronary aneurysms developed in a child of Kawasaki disease with only 3 days of fever

Prolonged fever, 5 days or more, is the cardinal feature of Kawasaki disease. We described a 5-year-old boy with initial presentations of fever, conjunctivitis, and strawberry tongue. The fever only lasted for 3 days. However, giant coronary aneurysms developed later. This patient reminds us that coronary complications could happen even the fever is less than 5 days. Criteria of fever duration might need reconsideration.

Performance of 2004 American Heart Association recommendations for treatment of Kawasaki disease

OBJECTIVE

The 2004 American Heart Association (AHA) statement included a clinical case definition and an algorithm for diagnosing and treating suspected incomplete Kawasaki disease (KD). We explored the performance of these recommendations in a multicenter series of US patients with KD with coronary artery aneurysms (CAAs).

METHODS

We reviewed retrospectively records of patients with KD with CAAs at 4 US centers from 1981 to 2006. CAAs were defined on the basis of z scores of >3 or Japanese Ministry of Health and Welfare criteria. Our primary outcome was the proportion of patients presenting at illness day < or =21 who would have received intravenous immunoglobulin (IVIG) treatment by following the AHA guidelines at the time of their initial presentation to the clinical center.

RESULTS

Of 195 patients who met entry criteria, 137 (70%) met the case definition and would have received IVIG treatment at presentation. Fifty-three patients (27%) had suspected incomplete KD and were eligible for algorithm application; all would have received IVIG treatment at presentation. Of the remaining 5 patients, 3 were excluded from the algorithm because of fever for <5 days at presentation and 2 because of <2 clinical criteria at >6 months of age. Two of these 5 patients would have entered the algorithm and received IVIG treatment after follow-up monitoring. Overall, application of the AHA algorithm would have referred > or =190 patients (97%) for IVIG treatment.

CONCLUSIONS

Application of the 2004 AHA recommendations, compared with the classic criteria alone, improves the rate of IVIG treatment for patients with KD who develop CAAs. Future multicenter prospective studies are needed to assess the performance characteristics of the AHA algorithm in febrile children with incomplete criterion findings and to refine the algorithm further.

Severe triple vessel coronary artery disease and aneurysms in a young white man: disease progression of childhood Kawasaki disease

Kawasaki disease usually affects younger age groups, but cardiac sequelae of 'missed' (incomplete) childhood Kawasaki disease may first present in adult life. We report a case of a 28-year-old white man presenting with ST elevation myocardial infarction and later found to have triple vessel coronary artery aneurysmal disease, probably secondary to childhood Kawasaki disease for which he underwent cardiac bypass surgery. The patient has remained well and asymptomatic at 1-year follow-up. This case is highlighted as the incidence of Kawasaki disease is relatively low among the white population, and yet there are increasing reports of adult patients presenting with coronary artery aneurysmal disease secondary to childhood Kawasaki disease. There has been a relative paucity of reports of surgical revascularization for adult survivors of childhood Kawasaki disease. This report also emphasizes the importance of early recognition and aggressive treatment of the often missed, incomplete, form of Kawasaki disease, which may reduce the risk of late development of coronary artery aneurysms. There should be a high index of suspicion of Kawasaki disease in young adults presenting with aneurysmal coronary artery disease with no significant coronary risk factors and in the absence of generalized atherosclerosis.

Cutaneous manifestations of cardiovascular diseases

Cardiovascular diseases may affect multiple organ systems including the skin. By identification of specific cutaneous findings, dermatologists may be the first physician to diagnose an underlying cardiovascular disease. This article discusses a number of cardiac disorders with prominent skin findings in addition to general dermatologic signs suggestive of cardiovascular disease.

Monthly observation of the number of patients with Kawasaki disease and its incidence rates in Japan: chronological and geographical observation from nationwide surveys

Background

Although the epidemiologic features of Kawasaki disease for Japan have been observed, recently, chronological and geographical observations of the number of patients and incidence rate of the disease have not been conducted using observation units smaller than the whole country.

Methods

We used the recent 5 nationwide surveys (the 15th to 19th) of Kawasaki disease in Japan, which covered patients for 10 years, i.e., between 1997 and 2006. The monthly number of patients by prefecture was calculated, and the number was corrected by the response rate of the target institutes of the prefecture. Chronological changes in the number of patients were observed by district. Geographical changes in the incidence rates were observed bimonthly by prefecture for the recent 6 years, from 2001 through 2006.

Results

On the whole, the monthly number of patients increased gradually. For each year, the number was the highest in January and the lowest in October; it was relatively high during summer as well. Some differences existed among the districts with regard to the monthly observations. Bimonthly observations of the incidence rate by prefecture revealed the differences in the characteristics of the epidemics in different geographic areas.

Conclusion

The chronological and geographical changes in the occurrence of Kawasaki disease in Japan for the recent 10 years suggested the involvement of one or more infectious agents in the occurrence of the disease.

Kawasaki disease in a pediatric intensive care unit: a case-control study

OBJECTIVES

We conducted a case-control study to ascertain the clinical presentations, risk factors, and clinical outcomes of children who had Kawasaki disease and were admitted to the ICU of our children's hospital.

METHODS

We reviewed charts of all children who had a discharge diagnosis of Kawasaki disease and were admitted to the ICU from 1995 through 2007. For each patient, we identified 3 season-matched control subjects who had Kawasaki disease and were not admitted to the ICU.

RESULTS

We identified 423 patients with Kawasaki disease. Of those, 14 (3.3%) were admitted to the ICU and met our inclusion criteria. ICU admission diagnoses were most commonly toxic shock or septic shock. Thirteen (92.8%) of 14 patients who were admitted to the ICU met criteria for complete Kawasaki disease before treatment. There was no significant difference in age in ICU patients compared with season-matched control subjects with Kawasaki disease. ICU patients were significantly more likely to be female and to have higher band counts, lower platelet counts, lower albumin levels, and higher C-reactive protein values. Time from admission to treatment with intravenous immunoglobulin was delayed in ICU patients. ICU patients were more likely to have intravenous immunoglobulin-refractory disease and require therapy with a second dose of intravenous immunoglobulin, infliximab, or steroids.

CONCLUSIONS

We present a case-control study of patients who had Kawasaki disease and presented severely ill, in shock, and requiring admission to the ICU. These patients frequently were misdiagnosed because of failure to appreciate the full spectrum of disease severity seen in patients with Kawasaki disease. These patients' illnesses was often mistaken for toxic or septic shock, leading to a delay in treatment with intravenous immunoglobulin. Patients who have Kawasaki disease and are admitted to the ICU are at increased risk for intravenous immunoglobulin-refractory disease and may be at risk for development of more severe coronary artery disease.

Epidemiologic features of Kawasaki disease in Japan: results from the nationwide survey in 2005-2006

BACKGROUND

The most recent epidemiologic features of Kawasaki disease are unknown.

METHODS

The 19th nationwide survey of the disease was conducted in 2007, targeting patients who were affected by this disease in 2005 and 2006. All pediatric departments in hospitals with 100 or more beds and pediatric hospitals were asked to report all Kawasaki disease patients during the 2 survey years.

RESULTS

From 1543 departments and hospitals, a total of 20475 patients (10041 in 2005 and 10434 in 2006) were reported. There were 11892 male patients and 8583 female patients. The average annual incidence rate was 184.6 per 100000 children aged 0-4 years. The number of patients and the incidence rate have increased significantly during the past 12 years. The age-specific incidence rate was distributed monomodally with a peak at 6-8 months of age. The prevalence of cardiac lesions in the acute phase of the disease and of cardiac sequelae were higher among infants and old patients.

CONCLUSION

The number of patients with Kawasaki disease and its incidence rate in Japan are continuously increasing.

Increasing incidence of Kawasaki disease in Japan: nationwide survey

BACKGROUND

The last nationwide survey of Kawasaki disease in Japan was conducted in 2003; the epidemiologic features of the disease in Japan since then are unknown.

METHODS

All the hospitals with a pediatric department and a bed capacity of > or =100, or hospitals having a bed capacity of <100 but specializing in pediatrics in Japan were asked to report (by mail) all patients with Kawasaki disease who visited the hospital due to the disease in 2003 and 2004.

RESULTS

Of the 2335 hospitals asked to participate, 1058 reported 19,138 patients with Kawasaki disease during the 2 year period 2003-2004. The annual incidence in 2004 reached 174.0 per 100,000 children under 5 years of age. The yearly number of patients and annual incidence increased significantly after the last nationwide epidemic of the disease in 1986. The number of patients was largest in January and lowest in October. The age-specific incidence was highest for those aged 9-11 months, and 88.9% of the patients were under 5 years of age. Of the reported patients, 2595 (13.6%) had cardiac lesions in the acute phase of the disease and 844 (4.4%) had cardiac sequelae 1 month after the onset of the disease.

CONCLUSION

The number of patients and the incidence of Kawasaki disease in Japan has increased year by year in the last two decades.

Effect of revision of Japanese diagnostic criterion for fever in Kawasaki disease on treatment and cardiovascular outcome

BACKGROUND

The aim of this study was to investigate the effect of a revision of the fever criterion for initial intravenous immunoglobulin (IVIG) treatment, and cardiovascular sequelae, in the new Japanese diagnostic criteria for Kawasaki disease.

METHODS AND RESULTS

Patients who were reported in the 16th and 18th nationwide surveys in Japan were analyzed. New criteria group comprised patients who received the diagnosis of Kawasaki disease in the 18th nationwide survey (n=18,789). Old criteria group was comprised patients who received their diagnosis in the 16(th) nationwide survey (n=15,017). The difference between the new and old criteria for complete cases was only 1%. The proportion of patients who were treated with IVIG within 4 days of illness onset in the new criteria group was significantly lower than in the old criteria group (27.7% vs 30.7%). Multivariate logistic regression analysis identified criteria sex, age, recurrence, diagnosis, last day of initial IVIG and additional IVIG treatment as significant independent factors for cardiovascular sequelae.

CONCLUSIONS

The guideline revision improves diagnostic sensitivity somewhat, but reflects the clinical reality of the disease that approximately 30% of patients are treated with IVIG within 4 days of illness onset.

Coronary involvement in infants with Kawasaki disease treated with intravenous gamma-globulin

AIM

To analyze the clinical spectrum and the incidence of coronary involvement in infants with typical Kawasaki's disease (KD).

PATIENTS AND METHODS

A retrospective study was performed on children one year of age or younger diagnosed from February 1992 to January 2006 with typical KD. Children with incomplete forms of the disease were not included.

RESULTS

Twenty-five infants were diagnosed with KD during the study period. The median age of the patients was 10 months (range, 4-12 months). All children but one received intravenous gammaglobulin (IVIG), 84% before the 10th day of disease. Seven patients (28%) required the administration of more than one dose of IVIG, because persistence of fever. Coronary artery disease (CAD) was recorded in 6 cases (24%), five of them being boys. All patients with CAD were treated with ASA plus IVIG and 84% of them received this therapy within the first 10 days of the KD onset.

CONCLUSIONS

In spite of the exclusion of our study of incomplete presentations and of an early administration of IVIG in our patients, we have observed a high rate of infants who developed CAD, which is similar to the one reported in children who do not receive IVIG.